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NCLEX/CGFNS REVIEW BULLETS 6
• One major risk factor for the development of pernicious anemia is gastric resection. Inadequate iron in the diet is not specifically associated with this type of anemia but is associated with iron-deficiency anemia. Central nervous system and musculoskeletal manifestations may occur as a result of pernicious anemia. Polycythemia vera is defined as the increase in both the number of circulating erythrocytes and the concentration of hemoglobin within the blood. It is classified as a myeloproliferative disorder, meaning overgrowth of bone marrow. The cause remains unknown, although it is possibly a form of malignancy similar to leukemia and is often considered a premalignant condition, sometimes referred to as myeloproliferative dyscrasia. Irondeficiency anemia occurs as a result of poor intake of iron. The lack of the intrinsic factor produces pernicious anemia. Bone marrow aspiration biopsy is a key diagnostic tool for confirming the diagnosis of leukemia and for identifying malignant cell types. Lumbar puncture may determine the presence of blast cells in the central nervous system. Radiographic tests may detect lesions and sites of infection. A lymphangiogram may be performed to locate malignant lesions and accurately classify the disease. When the neutrophil count is less than 500/mm3, the client is at risk for infection; therefore, monitoring the oral temperature is a critical nursing intervention. When the neutrophil count is less than 1000/mm3, the client is at risk for infection. A platelet count less than 20,000/mm3 would place the client at risk for hemorrhage. The breasts become tender early in pregnancy as a result of the increased levels of estrogen and progesterone. A self-care measure for breast tenderness includes wearing a well-fitting brassiere that provides support for the breasts and decreases discomfort. Constipation may result from slowing of peristalsis, caused by increased levels of progesterone, displacement of the intestines by the expanding uterus, lack of activity, and inadequate fluid intake. Self-care measures for constipation include increasing daily fluid intake and whole grains and roughage in the diet and exercising regularly.

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Vaginal discharge called leukorrhea is common in pregnant women because of the increased mucus production by the endocervical gland. The mucus should be clear or slightly whitish and mucoid in appearance. Clinical manifestations indicative of alcohol abuse during the prenatal period include poor weight gain, hypoglycemia, tremors at rest, nausea, weakness, anxiety, slurred speech, unsteady gait, and sweating, especially of the palms and forehead, as well as generalized sweating. After assessment of pitting edema, if the nurse notes a slight indentation, it is documented as a 1+ edema. A 2+ edema is an indentation approximately 1/4-inch deep. A 3+ edema is an indentation approximately 1/2-inch deep, and a 4+ edema is an indentation approximately 1-inch deep. To evaluate the deep tendon reflexes, the client’s lower leg is exposed, and one hand is placed under the knee to raise it slightly off the bed. A percussion hammer is used to strike the patellar tendon just below the patella. The normal response is extension and thrusting of the foot upward. The normal response is extension and thrusting of the foot forward. A 1+ response indicates a diminished response, 2+ indicates normal, 3+ indicates increased, or brisker than average, and 4+ indicates very brisk, or hyperactive. The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. A slider board would be useful in transferring a client who cannot move from a bed to a stretcher or a wheelchair. The facial nerve (CN VII) has both motor and sensory divisions. Common symptoms of dysfunction of this nerve include an inability to close the eye and to blink automatically, facial asymmetry, drooling and inability to swallow secretions, loss of the ability to form tears, and possible loss of taste on the anterior two thirds of the tongue. Bell’s palsy, fracture of the temporal bone, and parotid lacerations or contusions are often responsible for these symptoms. The vestibulocochlear nerve (CN VIII) is responsible for auditory acuity as well as bone and air conduction. The audiometer assesses the client’s hearing, whereas the tuning fork tests bone and air conduction. Nystagmus is characterized by fine involuntary eye movements. Ataxia is a disturbance in gait. Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and eyes closed. This assessment technique may be done to detect small changes in muscle 2

strength that might not otherwise be noted. Hyperreflexia is an excessive reflex action. • With an impaired corneal (blink) reflex, the client is at risk for the eyes becoming dry and also for corneal abrasions if foreign matter comes in contact with the eye. Use of sterile saline drops helps keep the eyes lubricated. An eye patch would have to be used carefully because corneal abrasion could result if the cornea comes in contact with the patch. Introduction of a foreign object (a cotton ball) inside the lower eyelid also risks corneal abrasion. Taping the eye shut could impair the client’s vision, putting the client at risk for another injury, such as a fall. Clients with confusion from neurological dysfunction respond best to a stable environment, which is limited in the amount and types of sensory input. The family can provide sensory cues and give clear, simple directions in a positive manner. Confusion and agitation are reduced when environmental stimuli (television and multiple visitors) are minimized and when personal articles are visible to the client. Ménière’s disease results from a disturbance in the fluid of the endolymphatic system. The cause of the disturbance is unknown. Attacks may be preceded by a feeling of fullness in the ear or by tinnitus. Headaches are not associated with this disorder. The three characteristic symptoms of Ménière’s disease are tinnitus, sensorineural hearing loss on the involved side, and severe vertigo accompanied by nausea and vomiting. After the acute phase of Ménière’s disease, remission occurs, but symptoms of the disease will recur with two or three acute attacks occurring per year. As this pattern of attacks and remissions develops, fewer symptoms occur during the acute phase. A complete remission eventually occurs with some degree of hearing loss, varying from slight to complete. It takes several weeks before all symptoms subside after an attack, leaving a loss of hearing in the involved ear. Medical interventions during the acute phase of Ménière’s disease include using atropine or diazepam (Valium) to decrease the autonomic nervous system function. Diphenhydramine (Benadryl) may be prescribed for its antihistamine effects, and a vasodilator also will be prescribed. The client will remain on bed rest during the acute attack, and when allowed to be out of bed, the client will need assistance with walking, sitting, or standing. Management during remission includes the use of diuretics to decrease the fluid and thereby decrease pressure in the endolymph. Antihistamines, 3

vasodilators, and diuretics may be prescribed for the client. A low-salt diet is prescribed for the client to reduce fluid retention. The major goal of treatment is to preserve the client’s hearing, and careful medical management helps achieve this in most clients with Ménière’s disease. • After stapedectomy, the client is instructed to keep water out of the ear canal for at least 3 weeks and to avoid swimming for 6 weeks. The client also is instructed to avoid coughing and sneezing and to avoid bending and lifting heavy objects or other strenuous activities for at least 3 weeks. Air travel is avoided for 4 weeks. If sudden hearing loss, fever, or severe persistent vertigo or dizziness develops, the physician should be notified. The client with urethritis from chlamydial infection should not engage in any form of sexual activity (intercourse, as well as oral-genital or oral-anal contact) until the client is fully cured. At that point, the client also should use condoms to prevent reinfection. To conduct a hearing test, The examiner should stand 1 to 2 feet away from the client and ask the client to block one external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately. Spinal shock occurs immediately after an injury as a result of disruption of the communication pathways. These assessment findings noted in the question indicate spinal shock. Hypertension is noted in autonomic dysreflexia. Insects that make their way into an ear are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because this material expands with hydration, and the impaction becomes worse. Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Clients with meniere's disease are instructed to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Clients are advised to stop smoking because of its vasoconstrictive effects. Hypokalemia is indicated by a potassium level of less that 3.5 mEq/L. Clinical manifestations include muscle weakness, paralysis, leg cramps, decreased 4

bowel sounds, weak and irregular pulse, and cardiac dysrhythmias (tachycardia or bradycardia). Clinical manifestations also may include hypotension, ileus, irritability, and fatigue. Nausea may or may not occur. • Killed or inactivated vaccines are vaccines that contain pathogens made inactive by either chemicals or heat. These vaccines, which are noninfectious, cause the body to produce antibodies. Their disadvantage is that they elicit a limited immune response from the body; therefore several doses are required. Examples of this type of vaccine include the Salk polio, the rabies, and the pertussis vaccines. Animal serums (antitoxins) are derived from the serum of immunized animals. These vaccines have the disadvantage of being foreign substances, which may cause hypersensitivity reactions. Thus a history and sensitivity testing should precede vaccine administration. The serums derived with this method are used to stimulate production of antibodies for hepatitis, chickenpox, rabies, diphtheria, smallpox, cytomegalovirus (CMV), botulism, snakebites, and spider bites. The ventral gluteal site may be used for intramuscular injections in older children. In children who have not yet developed the gluteal muscle (those younger than 2 years), the preferred site for intramuscular injections is the anterolateral aspect of the thigh. The deltoid muscle can be used in children 18 months or older; however, in an 11-year-old child, the ventral gluteal muscle is the preferred site. Haloperidol is an antipsychotic. The nurse evaluates for a therapeutic response by noting the client’s interest in surroundings, improvement in selfcare, increased ability to concentrate, and a relaxed facial expression. When giving DPT, Hib, and hepatitis B vaccines simultaneously, the nurse should administer the most reactive vaccine (DPT) in one leg and inject the others, which cause a smaller reaction, into the other leg. Any immunization may cause an anaphylactic reaction. All offices and clinics administering immunizations must have epinephrine 1:1000 available. Pediatric syringes are needed to administer the immunization. Generally, a needle that is 2/8-inch or longer is adequate to administer immunizations for a normal 4-month-old infant. The client with fractured ribs is predisposed to atelectasis and pneumonia owing to the effects of shallow breathing, which leads to decreased coughing, accumulation of secretions, and subsequent pneumonia. The client could have hemoptysis or pneumothorax at the time of injury if the rib has pierced 5

lung tissue or the pleural cavity, but these problems are not likely to occur after the first 24 to 48 hours after the injury. • • The normal respiratory rate is 12 to 20 breaths/minute, whereas the normal oxygen saturation range is 95% to 100%. The care of the client in respiratory failure is focused on maintaining effective respirations and conserving energy. Fluid balance and nutrition are important, but energy conservation takes priority. Energy conservation will conserve oxygen. Rubella has an incubation period of 14 to 21 days. The infectious period ranges from 10 days before the onset of symptoms to 15 days after the rash appears. The client with rheumatoid arthritis may be prescribed a dose of aspirin of 1000 to 1600 mg/day. At these high doses, aspirin is frequently toxic. Clients should be instructed to take aspirin with food and to watch for clinical manifestations of gastrointestinal (GI) bleeding, easy bruising, and tinnitus. The incubation period for mumps is usually 16 to 18 days but may extend to 25 days. The infectious period is usually 1 to 2 days (7 days before swelling to 9 days after onset). The incubation period for scarlet fever is 1 to 7 days. The infectious period is the acute stage until 36 hours after antimicrobial therapy is initiated. Rubeola is transmitted via airborne particles or by direct contact with infectious droplets. Mumps is transmitted via airborne droplets, salivary secretions, and possibly the urine. Rubeola has an infectious period that ranges from 1 to 2 days before the onset of symptoms to 4 days after the rash appears. Infectious period for mumps usually ranges from 1 to 2 days Rubeola is transmitted via airborne particles or direct contact with infectious droplets. The treatment of measles is symptomatic, whether the child is hospitalized or remains at home. If hospitalized, however, the child will require respiratory isolation. During the febrile period, the child should be restricted to quiet activities and bed rest. Respiratory isolation for a child with measles requires masks for those in close contact with the child. Gowns and gloves are not specifically indicated. Strict hand washing is necessary. 6

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Articles that are contaminated should be bagged and labeled before reprocessing. • In infants and non–toilet-trained children, a urine specimen may be collected by attaching a bag to the perineum. The perineal area must be meticulously cleansed and the specimen collected within 30 minutes. If the child or infant does not void within 30 minutes, the bag is changed. Urine can be collected by urethral catheterization, but this is not the best method because it will introduce bacteria into the bladder. Glomerulonephritis is characterized by inflammation of the capillaries contained in the glomerulus. It can result from different causes, such as an infection, a systemic disease process, or a primary defect in the glomerulus itself. In the child with glomerulonephritis, fluid intake should be limited, as prescribed. In children with fluid excess, pulmonary edema may develop. A low-sodium diet is followed as prescribed because excessive sodium will increase fluid retention. Weight should be obtained to determine fluctuations in fluid status. The child may tire easily, so playtime should be limited to short periods and extended as the condition improves. Hypospadias is a congenital anomaly in which the actual opening of the urethral meatus is below the normal placement on the glans penis. Bladder exstrophy is a congenital anomaly characterized by the extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall. Postoperative instructions for parents of a child who underwent a myringotomy with insertion of tympanostomy tubes includes that if a small amount of reddish drainage is normal for the first few days after surgery; however, the parents should report any heavier bleeding or bleeding that occurs after 3 days. The parents should be instructed to report any fever or increased pain. The child should not blow the nose for 7 to 10 days. Baths and lake water are potential sources of bacterial contamination, and chlorinated swimming pools can be irritative to the tympanic membranes with tubes. The child should place earplugs or cotton balls covered with petroleum jelly in the ears during baths and shampoos. Swimming is allowed only with earplugs and with the physician’s approval. Diving and swimming deeply underwater are prohibited.

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Discharge instructions to a mother regarding the care of her 10-year-old child who has pharyngitis includes antibiotics should be taken for the entire prescribed course, even if the child is feeling better and is free of symptoms. The older child may gargle with saline. Warm or cool compresses may be applied to the throat. A follow-up with a repeat throat culture should be done 3 to 5 days after completing the course of the antibiotics. Clear, cool liquids are provided when the child is fully awake. Citrus, carbonated, and extremely hot or cold liquids are avoided because they irritate the throat. Milk and milk products, including puddings and ice cream, are avoided initially until the child has tolerated clear liquids well. This is done because milk products can coat the throat and cause the child to clear it, thus increasing the risk of bleeding. Acute epiglottitis is caused by bacteria, usually Haemophilus influenzae type B. Viral epiglottitis is rare. It has an abrupt onset, causes swelling and inflammation of the epiglottis, and may rapidly progress to complete airway obstruction. Virazole is an antiviral respiratory medication that is used to interfere with RNA and DNA synthesis, inhibiting viral replication. Administration is via hood, facemask, or oxygen tent. Atrial septal defect is an opening between the two atria that allows oxygenated and unoxygenated blood to mix. Left-to-right shunting of blood occurs because of the higher pressure on the left side of the heart. Ventricular septal defect is an opening between the two ventricles allowing oxygenated and unoxygenated blood to mix. Patent ductus arteriosus involves an artery that connects the aorta and the pulmonary artery during fetal life. Atrioventricular canal defect occurs as a result of inappropriate fetal development of endocardial cushions. Atrial septal defect is a left-to-right heart shunt. In a left-to-right shunt, blood is shunted to the right side of the heart because the left side is normally functioning under a higher pressure than the right side. This shunting allows oxygenated blood and unoxygenated blood to mix. This results in increased pulmonary blood flow because the abnormal communication, or opening, sends more blood to the right side of the heart through the opening than is normal. An atrioventricular canal defect is a left-to-right shunt. Blood is shunted to the right side of the heart because the left side is normally functioning under a higher pressure than the right side. This shunting allows oxygenated and unoxygenated blood to mix. It results in increased pulmonary blood flow

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because the abnormal communication, or opening, sends more blood to the right side of the heart through the opening than is normal. • In some children with patent ductus arteriosus, no symptoms occur, and the defect closes spontaneously. Measures to reduce symptoms of congestive heart failure (CHF) must be undertaken. Surgical closure, if performed, is done via a left thoracotomy and without cardiopulmonary bypass. Indomethacin (Indocin) is sometimes used to promote ductal closure in premature infants. Fear is the most appropriate problem because the breathlessness and dyspnea are making the client upset. A limited fluid intake can predispose the client to dehydration and respiratory infection. This is because dehydration impairs the action of the cilia in the respiratory tree. Aneurysm precautions include placing the client on bed rest in a quiet setting. Lights are kept dim to minimize environmental stimulation. Any activity that increases the blood pressure (BP) or impedes venous return from the brain is prohibited, such as pushing, pulling, sneezing, coughing, or straining. The nurse provides all physical care to minimize increases in BP. For the same reason, visitors, radio, television, and reading materials are prohibited or limited. Stimulants such as caffeine and nicotine are prohibited; decaffeinated coffee or tea may be used. Aminocaproic acid is an antifibrinolytic agent that prevents clot breakdown or dissolution. Nimodipine is a calcium channel-blocking agent that has an affinity for cerebral blood vessels. It is used to prevent or control vasospasm in cerebral blood vessels, thereby reducing the chance for rebleeding of the aneurysm. It is typically ordered for 3 weeks duration. Typically, seizure assessment includes the time the seizure began, part(s) of the body affected, the type of movements and progression of the seizure, changes in pupil size, eye deviation or nystagmus, client condition during the seizure, and postictal status. Generalized seizures are seizures that are bilaterally symmetric and have no focal point of onset. Partial seizures are seizures that begin locally and include simple partial seizures (without impaired level of consciousness), complex partial seizures (with impaired level of consciousness), and partial seizures secondarily generalized. 9

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Positioning the client on one side with the head flexed forward allows the tongue to fall forward and facilitate drainage of secretions, which could help prevent aspiration. The nurse would also remove restrictive clothing and the pillow and raise the padded side rails, but these would not decrease the risk of aspiration. Rather they are just general safety measures to use during seizure activity. The nurse would not raise the client’s head of bed. Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a thrombotic CVA, the client may experience a transient loss of speech, hemiplegia, or paresthesias on one side of the body. Signs and symptoms of thrombotic CVA vary, but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with CVA experience signs and symptoms similar to cerebral embolism or intracranial hemorrhage. In addition, most clients do not have repeated episodes of loss of consciousness. The client does not complain of difficulty with night vision as part of this clinical problem. After CVA, the client often experiences periods of emotional lability, which is characterized by sudden bouts of laughing or crying, or by irritability, depression, confusion, or being demanding. This is a normal part of the clinical picture for the client with this health problem, although it may be difficult for health care personnel and family members to deal with Hemiparesis is a weakness of the face, arm, and leg on one side. The client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed, and food is placed on the unaffected side of the mouth. The client is given ample time to chew and swallow and should not eat quickly because this could cause choking. Liquids are thickened to avoid aspiration. Homonymous hemianopsia is loss of one half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The client is exhibiting clinical signs and symptoms of aspiration, which include fever, dyspnea, crackles or rhonchi, decreased arterial oxygen levels, and confusion. Other symptoms that occur with this complication are difficulty in managing own saliva, or coughing or choking while eating. Because this is a medical complication, the most appropriate action is to notify the physician, who will then order definitive therapy. 10

Unilateral neglect is an unawareness of the paralyzed side of the body, which increases the client’s risk for injury. The nurse’s role is to refocus the client’s attention to the affected side. Personal care items, belongings, bedside chair, and commode are all placed on the affected side. The client is taught to scan the environment to become aware of that half of the body and is approached on that side by family and staff as well. Clients with aphasia after CVA often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include: speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse also suggests to avoid shouting (because the client is not deaf), appearing rushed for a response, and allowing family members to give all the responses for the client. Placing an eye patch over one eye in the client with diplopia removes the second image and restores more normal vision. The patch is alternated on a daily basis to maintain the strength of the extraocular muscles of the eyes. The client with myasthenia gravis has weakness after periods of exertion and near the end of the day, and medication is prescribed to alleviate weakness, particularly at these times. The nurse works with the client to space out activities to conserve energy and regain muscle strength by resting between activities. The client also is instructed to take medication as prescribed. The client with myasthenia gravis experiences dysphagia and a nasal quality to speech when the muscles of chewing and swallowing are involved. The nurse listens attentively and verbally verifies what the client has said. Other helpful techniques are to ask questions requiring a yes or no response and to develop alternative communication methods (letter board, picture board, pen and paper, flash cards). Plasmapheresis is a process that separates the plasma from the blood elements, so that plasma proteins that contain antibodies can be removed. It is used as an adjunct therapy in myasthenia gravis and may give temporary relief to clients with actual or impending respiratory failure. Usually three to five treatments are required. Myasthenic crisis is often caused by undermedication and responds to the administration of cholinergic medications such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Cholinergic crisis (the opposite problem) is caused by excess medication and responds to the withholding of medications.

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Signs and symptoms of cholinergic crisis in a client with myasthenia gravis include general weakness and difficulty chewing, swallowing, speaking, and breathing. Nausea and vomiting, abdominal cramping, diarrhea, and increased production of body secretions also occur. It is due to overmedication and is treated by withholding all medications and supporting the client’s respiratory function until symptoms improve. Inadequate or inappropriate medication therapy can result in either myasthenic or cholinergic crisis. It is very important for the client to take medications correctly to maintain blood levels that are within the therapeutic range. Clients with myasthenia gravis are taught to space activities over the day to conserve energy and restore muscle strength. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress. Discharge instructions to a client with myasthenia gravis includes the client avoids swallowing any type of food or drink with the head lifted upward. This action could cause aspiration because it opens the glottis. The client should also refrain from talking with food in the mouth (glottis is open). The client should sit bolt upright while eating, cut food into very small pieces, chew thoroughly, and tip the chin downward to swallow. The parkinsonian gait is characterized by short, accelerating, shuffling steps. The client leans forward with the head, hips, and knees flexed, and has difficulty starting and stopping. An ataxic gait is staggering and unsteady. A dystrophic gait is broad-based and waddling. A festinating gait is accelerating with walking on the toes. The client with Parkinson’s disease has a tendency to become withdrawn and depressed, which can be limited by encouraging the client to be an active participant in his or her own care. The family also should give the client encouragement and praise for perseverance in these efforts. The family should plan activities intermittently throughout the day to inhibit daytime sleeping and boredom. The major dietary source of calcium is from dairy foods, including milk, yogurt, and a variety of cheeses.

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